Management of Coronary Vascular Disorders

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  • 1. Management of Patient with Coronary Vascular Disorders Chapter 28
  • 2. Coronary Artery Disease (CAD)
    • Most prevalent type of CVD in adults
    • Decreased blood flow through coronary arteries = myocardial ischemia/infarction
    • Ischemia results from insufficient O2 supply to myocardium
    • Atherosclerosis is leading contributor
  • 3. CAD
    • Describe common manifestations of Coronary Artery Disease.
    • Discuss risk factors for CAD.
      • Modifiable
      • Non-modifiable
    • Describe Coronary Artery Disease Risk Equivalents.
  • 4. Atherosclerosis
    • Describe the pathophysiology of atherosclerosis.
    • Review Figure 28-1, p. 860
  • 5. Acute Coronary Syndromes
    • Serious manifestation of CAD
    • Amount of disruption of the plaque determines the degree of obstruction of the coronary artery and specific disease process:
        • Unstable angina
        • Non-ST elevation MI
        • ST elevation MI
  • 6. Angina Pectoris
    • “ Strangling of the chest”
    • Imbalance between O2 supply and demand
    • Compare and contrast Stable and Unstable Angina Pectoris.
    • Describe associated clinical manifestations.
  • 7. Angina Pectoris-- Management
    • Medical Management
    • Pharmacologic therapy
      • Nitroglycerin
      • Beta-adrenergic blockers
      • Calcium channel blockers
      • Antiplatelets
      • Anticoagulants
    • Oxygen therapy
    • Nursing Management
    • Treat associated symptoms
      • Immediate rest
      • Oxygen
      • assessment
      • ECG
      • Nitroglycerin
    • Reduce anxiety
    • Prevent pain
  • 8. Myocardial Infarction
    • When does a myocardial infarction occur?
    • What degree of blood flow reduction results in ischemia?
    • What will occur if blood flow is not restored to the myocardium?
    • What is the most common cause of coronary artery occlusion?
    • What are other causes?
  • 9.  
  • 10. Process of Infarction
    • Dynamic process that evolves over several hours
    • Normal conduction and contractile functions are suppressed
    • Automaticity and ectopy are enhanced
    • Heart rate and force of contraction are increased
    • Oxygen requirements increase
  • 11. Physiologic Response to Infarction
    • Will take up to six hours for obvious changes to occur in the heart (blue and swollen)
    • After 48 hours (gray with yellow streaks)
    • By 8-10 days granulation tissue forms at edges of necrotic tissue
    • Within 2-3 months scarring develops which changes the shape of the left ventricle (ventricular remodeling)
    • Remodeling may ↓ L ventricular function, cause heart failure, and ↑ morbidity and mortality
  • 12. MI Assessment: History
    • Query patient about chest pain
      • If experiencing acute chest discomfort, delay history and treat discomfort
    • Obtain information about
      • Management of current episode of discomfort
      • Current medications
      • Family history of CAD
      • Presence of modifiable risk factors
  • 13. MI Assessment: Pain
    • Must differentiate type of chest discomfort and identify source
    • Query patient to determine characteristics of discomfort
      • Onset
      • Location
      • Radiation
      • Intensity
      • Duration
      • Precipitating and facilitating factors
  • 14. MI Assessment: Pain
    • Remember:
      • angina is ischemic pain and usually improves when oxygen supply/demand disparity resolves.
      • MI does not usually resolve with simple measures
    • Associated symptoms: nausea, vomiting, diaphoresis, dizziness, weakness, palpitations, and shortness of breath
  • 15. MI Assessment: Cardiovascular
    • Blood pressure
    • Heart rate
    • Cardiac rhythm
    • Distal peripheral pulses
    • Skin temperature
    • Heart sounds
    • Respiratory rate
    • Breath sounds
  • 16. MI Assessment: Psychosocial
    • Denial is common early reaction
      • Can be normal part of adapting to stressful event
      • Detrimental if denial interferes with identification of symptom
    • Other common reactions
      • Fear
      • Anxiety
      • anger
  • 17. MI: Laboratory Assessment
    • Cardiac Enzymes
      • Creatine kinase (CK)
      • CK-MB isoenzyme
    • Myoglobin
      • Found in serum 2-3 hours after MI, but is not cardiac specific
      • Always increases within 3-6 hours after MI, if not increased at 6 hour mark can rule out MI
    • Troponin T and I
    • Increased WBC
  • 18. Cardiac Markers for MI
    • Creatine Kinase (CK)
    • Cardiac enzyme released after injury
    • Levels rise 3-12 hours after acute MI
    • Levels peak in 24 hours
    • Levels to normal within 2-3 days
    • MB band is specific to myocardial cells
      • >3% indicates MI
  • 19. Cardiac Markers for MI
    • Troponin
    • Myocardial muscle protein released after injury
    • Two subtypes: T and I
    • Greater sensitivity and specificity for myocardial injury
    • Levels rise in 3-12 hours after MI
    • Levels peak in 24-48 hours
    • Levels back to baseline over 5-14 days
    • Used for diagnostic purposes in conjunction with CK and the MB fraction
  • 20. Acute MI: Other Diagnostic Tests
    • ECG
    • Stress Test
    • Thallium scans
    • MRI
    • Cardiac catheterization
    • (Discussed in Chapter 26)
  • 21. ECG Changes in MI
    • ST-segment elevation
    • T-wave inversion
    • Abnormal Q wave
  • 22. Acute MI: Collaborative Problems
    • Acute Pulmonary Edema
    • Heart Failure
    • Cardiogenic Shock
    • Dysrhythmias/Cardiac Arrest
    • Pericardial Effusion and Cardiac Tamponade
  • 23. Acute MI: Interventions
    • Pain Management:
    • Nitroglycerin
    • Morphine Sulfate
    • Supplemental O 2
    • Position of Comfort
    • Quiet and calm environment
  • 24. Acute MI: Interventions
    • Thrombolytics
    • Fibrinolytics dissolve clots and restore myocardial perfusion
    • Most effective when given within 6 hours of onset of MI
    • Client must be continuously monitored
    • Contraindications: Table 41-3, p. 850
    • During administration monitor for bleeding and report any signs to physician
  • 25. Acute MI: Interventions
    • Thrombolytics (cont)
    • Post administration observe closely for signs of bleeding by:
      • Documenting neuro status
      • Observing IV sites
      • Monitoring clotting studies
      • Observing for s/s of internal bleeding
        • Monitor Hemoglobin and Hematocrit
      • Testing stools, urine, emesis for occult blood
  • 26. Acute MI: Interventions
    • Glycoprotein (GP) Inhibitors
      • Target platelet component of the thrombus
      • Prevent fibrinogen from attaching to activated platelets at the site of a thrombus
      • Used in:
        • Acute coronary syndromes
        • During and before PCTA to ensure patency
        • Conjunction with fibrinolytics following MI
      • During administration nurse assesses closely for bleeding or hypersensitivity reactions
  • 27. Acute MI: Interventions
    • Drug Therapy
    • ASA
    • Beta-adrenergic blocking agent
    • ACE inhibitors
    • Calcium channel blockers
  • 28. Acute MI: Interventions
    • Cardiac Care Rehabilitation
    • Process which assists client with cardiac disease to achieve and maintain optimal functioning within the limits of the heart’s ability to respond to increases in activity and stress
      • Phase 1: begins with acute illness, ends with discharge from hospital
      • Phase 2: begins after discharge and continues through convalescence at home
      • Phase 3: long term conditioning
  • 29. Acute MI: Interventions
    • Cardiac Care Rehabilitation Phase 1
    • Nurse promotes rest while ensuring some limited mobility
    • Assistance is given for some ADL’s
    • Individualized– client’s progress at their own rate
    • Nurse encourages progressive ambulation
    • Nurse assesses heart rate, BP, respiratory rate and level of fatigue with each higher level of activity
    • Nurse should stop the activity and refrain from advancing activity if client develops any signs of activity intolerance
  • 30. Acute MI: Interventions
    • Coping
    • During acute phase antianxiety agents may be prescribed
    • Nurse assesses current coping mechanisms
      • Most common are denial, anger and depression
        • Denial which allows the client to minimize threat and use problem-focused coping mechanisms may be helpful in decreasing anxiety
        • Anger may represent an attempt to regain control of life
        • Depression may be the response to grief and loss of function
  • 31. Dysrhythmias
    • Cause of death in clients with MI who die prior to hospitalization
    • 70-90% of hospitalized MI clients have abnormal cardiac rhythms
      • Identify the dysrhythmia
      • Assess hemodynamic status
      • Evaluate client for chest discomfort
    • Treated when they cause
      • Hemodynamic compromise
      • Increased myocardial oxygen requirements
      • Predispose lethal ventricular dysrhythmias
  • 32. Dysrhythmias
    • Inferior MI
      • Bradycardias
      • 2nd Degree AV Blocks
      • Transient
      • Nurse monitors:
        • Cardiac rate & rhythm
        • Hemodynamic status
      • May need temporary pacer if hemodynamically unstable
    • Anterior MI
      • Venrticular irritability (PVCs)
      • 3rd Degree or Bundle Branch Block (serious complication)
      • Nurse observes closely for s/s of heart failure
      • May need pacemaker
  • 33. PTCA: Percutaneous Transluminal Coronary Angioplasty
    • Invasive, but nonsurgical technique to reduce frequency and severity of chest discomfort
      • Complexity and location assessed to determine whether client would benefit from procedure
      • May also be used during evolving MI
    • Procedure performed under fluoroscopic guidance in cardiac cath lab
      • Balloon inflation may be repeated until lesion is reduced or eliminated
      • Meds include: heparin, nitriglycerine or nifedipine
      • Stents may be placed at time of procedure
  • 34. PTCA: Post-Procedure Care
    • Monitor for potential problems
      • Acute closure of the vessel
      • Bleeding from insertion site
      • Reaction to the dye
      • Hypotension
      • Hypokalemia
      • dysrhythmias
    • Drug Therapy
      • Long term nitrate
      • Calcium channel blockers
      • ASA
      • Beta blocker and ACE inhibitor may be added
      • Glycoprotein inhibitors during initial hours
      • Potassium supplements if indicated
      • Coagulation with coumadin
  • 35. Coronary Artery Bypass Graft
    • Most common cardiac surgery
    • Indicated for clients who do not respond to medical management of CAD or when disease progression is evident
    • To be bypassed vessels should have proximal lesions with > 70% occlusion
    • Most effective when good ventricular function remains and ejection fraction is more than 40-50%
    • Requires Cardiopulmonary bypass during surgery
  • 36. CABG: Post-Op Care
    • Mechanical ventilation for 3-6 hours
    • Mediastinal tubes to waterseal drainage
    • Epicardial pacing wires
    • Hemodynamic monitoring
    • Observes closely for:
      • Dysrhythmias (ventricular ectopics, bradydysrhythmias, or heart block)
      • Fluid and electrolyte imbalances (K+ at 4-5)
      • Hypotension, hypothermia, hypertension
      • Cardiac tamponade
      • Altered cerebral perfusion
  • 37. Cardiac Tamponade
    • Blood accumulates around the heart
    • Medical emergency
    • Hallmarks in post-CABG patient:
      • Sudden cessation of previously heavy mediastinal drainage
      • JVD with clear lung sounds
      • Pulsus paradoxus
      • Equalization of PAWP and right artrial pressure
  • 38. Neurological Changes Post-CABG
    • Transient:
    • 75%; transient changes due to:
      • Anesthesia, CPB, air emboli, hypothermia
    • Experience:
      • Slowness to arouse
      • Memory loss
      • confusion
    • Usually return to baseline in 4-8 hours
    • Permanent
    • Changes may be associated with stroke during surgery
    • Experience:
      • Abn. pupillary response
      • Failure to awaken from anesthesia
      • Seizures
      • Absence of sensory or motor function
    • Monitor:
      • Neuro status q 30-60 min initially then q 2-4 hours